building a quality improvement infrastructure
DESCRIPTION
Aiming to stimulate and change the nature of the improvement dialogue within NHS boards across Scotland, Quality Improvement leaders, Martin Barkley, Pedro Delgado, Eibhlin McHugh and Elaine Mead presented current QI Infrastructure work both locally and nationally.TRANSCRIPT
Building a Quality Improvement Infrastructure Na8onal Execu8ve Event 12 May 2014
@NHSQI_Hub, #NHSSQII | www.qihub.scot.nhs.uk
WELCOME & OPENING Angiolina Foster CEO, Healthcare Improvement Scotland
LEADERSHIP FOR QUALITY IMPROVEMENT MarGn Barkley CEO, Tees, Esk and Wear Valleys NHS FoundaGon Trust
TEWV Quality Improvement System: Our journey to date
l Share learning
l Toyota
l Virginia Mason Medical Centre, Seattle
l Background
Background : TEWV l Formed April 2006 following merger of two successful
MH Trusts
l Foundation Trust July 2008
l 6000 staff
l 3600 square miles serving 1.6 million people
LOCATION OF TEWV
NETS Supports the quality strategy
l North East Transformation System l Vision
l Compact
l Methodology
l Toyota Production System / VMPS is the methodology
l 7 Pathfinder organisations including TEWV (2007)
Learning from Toyota l Staff, equipment, tools, supplies and product in perfect
harmony
l Respect for the staff
l “The art of the possible”
l “Toyota is a way of thinking rather than a company”
l Inspirational – what to aim for – it works!
The Toyota Way l Toyota is very process orientated with a belief that investment in
people and process get results rather than results orientated which leads to an important focus on the bottom line and less on problem solving
l Simply setting specific measurable goals and then measuring is motivatory – passion for measurement and feedback
l Align goals and objectives then measure progress l Set aggressive targets - visible charts showing progress at a
glance updated very frequently l Learning through relentless reflection and continuous
improvement l Apply lean in your own way – analyse your own situation, develop
innovative solutions - implement
Learning Implications from Hitachi & TEWV l Visiting / being on the Genba – can’t change things
otherwise
l Power of observation – leads to real understanding
l The tools work
l Importance of consistency of leadership
l Simulation / Change does not have to cost a lot of money
l Importance of testing / piloting
Involvement of Clinicians
l Huge support from Clinical Directors to the TEWV QIS l Real Leadership by Clinical Directors – in fact 3
nominated for different categories in the NHS Leadership Awards
l Winner of Royal College of Psychiatrists Medical Leader of the Year
Respect for the Staff l “Build trust with workers – treat them as key
stakeholders – don’t sack them –generate respect and commitment”
l Show respect by asking staff to do work that adds value, don’t be disrespectful by getting them to do things which do not add value
l Development of compact
Staff Involvement l Staff at all levels are able to be involved and engaged l It is the staff who determine what is changed and how
l “The staff know best” – it is the job of management to give them the tools to achieve change and improvement
l The importance of standardised ways of working, which staff can change if they can prove it is better.
Quality Equation
Quality = Appropriate (Outcome + Service) Waste
What are our compelling reasons? l Perfect (flawless) care is in our reach if we have the
discipline to do it
l The quest for the perfect patient experience for each and every patient
l To enable staff to do a great job because we are not expecting them / requiring them to do things that do not add value
l To make our resources go further in increasing the amount of health gain for local people
Key Issues l How to describe it / what language to use e.g. TPS? VMPS? l Quality improvement philosophy and quality improvement
methods
l How do we establish critical mass?
l How do we establish cadre of leaders and managers who fully understand this stuff ?
l How do we make it the way of doing things ?
l How do we establish a culture that constantly invites criticisms / suggestions for improvement and act on them ?
l How do we establish standard systems of work ?
Management / Leadership philosophy l The quality equation needs to be at the heart of what
we do
l It is everybody’s jobs to constantly improve quality
l “Management need to dedicate time to really learn this stuff for themselves and to teach it through their daily interactions ….. It’s got to be part and parcel of every day’s activities”
l We should constantly invite criticism, not praise, and suggestions for improvement
The TEWV Quality Improvement System
l Emulates the Toyota Production System and the Virginia Mason Production System
l Totality of approach
l Systematic use of the “tools and techniques”
l Development of staff compact
l Key methodology ( but not a panacea) for achieving our vision and strategic goals
Resources l 14 wte Improvement Specialists in the KPO (started 6) l 3 wte Admin staff in the KPO l 60+ Certified Leaders l 2000 staff have taken part in Improvement Events l TEWV QIS for Leaders (166) l TEWV QIS for Doctors – led by Clinical Director KPO l TEWV QIS for admin staff 50+ l “See and Feel” visits to VMMC (30+) l Japan ( 2+2)
COMPACT Trust Staff
Communications The Trust will strive to ensure honest and timely communications at all times.
Alignment To work in accordance with the values of the Trust and its strategic goals, mission (purpose) and vision.
Recognition The Trust will recognise staff who have achieved excellence and show commitment to value adding work.
Responsive To respond to the changing needs of patients and people who use our services, as well as changes to the requirements of other “customers” and changes in demand for services.
Training and Development The Trust will invest in the continuing professional development, training and education of staff in the skills and competencies required and adhere to all agreed training commitments.
Technical Expertise To keep skills and competencies up to date and relevant to their work, all of which will be evidence based.
Support The Trust will ensure that staff will be involved in and supported through the process of change and managing the process of change.
Embrace and Engage Willingness to support, co-operate with and contribute to quality improvement activities and especially with the testing of new ideas and innovations.
Work Environment The Trust will strive to provide a positive, healthy workplace for all staff which is characterised by enthusiasm and not cynicism; staff having the right equipment; the right colleagues and a good physical environment in which to work.
Teamwork To be supportive, positive and a good communicator with staff, people who use our services and all other “customers” e.g. GPs, PCTs, Social Services, etc.
Choice The Trust will give staff choices to ensure no compulsory redundancies should job numbers reduce as a consequence of quality improvement activities.
Flexibility In the context of significant change taking place in society and the NHS, staff will be flexible with regard to the breadth of work undertaken and the location of their work.
“The Trust will endeavour to be a great organisation to work for”
“My job is to provide the best possible customer experience”
Trust l Communications – honest & timely l Recognition – excellence & value adding work
l Training & Development – invest in skills & competencies
l Support – and involve staff through change
l Work environment – no cynicism & good environment
l Choice – avoid redundancies
The Trust will endeavour to be a great organisation to work for
Staff l Alignment -with Vision, Mission, Values & Goals l Responsive- to changing needs of our service users l Technical expertise – keeping skills up to date l Embrace and engage - with improvement activities l Teamwork – supportive , positive & communicator l Flexibility – with regard to work My job is to provide the best possible customer experience
Standard work l There can be no improvement in the absence of
standards l Need to develop standard ways of working :model lines
l Operation of Community Teams l Operation of Admission Wards (PIPA) l Operation of CRHTs l High dose anti-psychotics l Lithium
l Standard ways of working in support departments eg HR
l Patient pathways (RPDWs)
Timescales l This is for ever l By definition continuous improvement (Kaizen) is never
ending l We move “jojo” i.e. step by step
Kaizen is Forever and Endless
K A I Z E N M A I N T E N A N C E
Progress
Quality Development
PROGRESS OF THE TIME
TIME
How is TEWV doing ? : mixed l Second lowest Reference Costs of any MH Trust in England l HSJ MH Innovator of the Year
l Royal College MH Provider of the Year
l Royal College Medical Leader of the Year l Top for 2 years Staff Survey MH Trusts
l Top 20% Patient Survey MH Trusts l But not top
l And only moderate feedback from GP survey in key areas
l And miles and miles and miles away from being perfect
Reflections l Be patient, keep faith – it works. Constancy very imp. l Its not a panacea l No down sides only upsides l Staff engagement l Leadership – all but 2 Directors are trained certified
leaders and lead at least one event each year l Rapid change and improvement (ensure no blockages) l Its about quality rather than necessarily money e.g.
Virginia Mason is a zero waiting hospital l Alignment
Virginia Mason
l “The clear destination is perfection. The journey is about ongoing pursuit of the perfect patient experience; the highest quality service, and people development; and the attainment of a culture that totally supports innovation and learning.”
Sir John Oldham Quote "Today's visit has been inspiring. I know of no other organisation in the UK or Europe that is so comprehensively implementing
kaizen in a health care setting to the obvious benefit of patients , staff, and use of resources. The rest of the NHS should follow the example of Tees Esk and Wear
in meeting their own challenges."
Ques8ons?
Image source: http://blogs.reading.ac.uk/digitallyready/files/2013/03/Network.jpg
Discussion ques8on
What support do you need as a senior leader to create
the condiGons for QI?
Morning break 11:15 – 11:30
Image source: http://lifegirl1130.files.wordpress.com/2010/06/teabreak.png
CREATING THE CONDITIONS, PART 1: OPTIMISING HEALTH SYSTEM PERFORMANCE WITH THE TRIPLE AIM Pedro Delgado ExecuGve Director, InsGtute for Healthcare Improvement
Creating the conditions to
accelerate improvement – Part I
Triple Aim Pedro Delgado Executive Director @pedroIHI
Scotland Building a QI Infrastructure May 2014
Summary 1. Context and paradigms
2. The Triple Aim - introduction
3. Opportunities: framing, segments
“The brain is a far more open system than we ever imagined, and nature has gone
very far to help us perceive and take in the world around us. It has given us a brain
that survives in a changing world by changing itself.” ―
Norman Doidge, The Brain That Changes Itself: Stories of Personal Triumph from the Frontiers of Brain Science
O + A = R "We do not see things as they are,
we see them as we are"
Shared Global Challenges
• Financial constraints, the aging of the population, and the increasing burdens of chronic disease
• Unprecedented opportunities for redesign (paradigms, technology, etc)
• The Leader’s Role: A Quality Trilogy of Assurance, Improvement, and Innovation
www.thelancet.com Published online May 3, 2014 h=p://dx.doi.org/10.1016/S0140-‐6736(14)60616-‐4
37 million…
25 x 25 (2010-‐2025): cardiovascular diseases, chronic respiratory diseases, cancers,
and diabetes
…tobacco use, harmful alcohol use, salt intake, obesity, raised blood pressure, raised blood glucose and diabetes, and physical inac:vity
Disease Burden
Parrish RG. Measuring Population Health Outcomes.
Education & Counseling
Clinical Interventions
Long-Lasting Protective Interventions
Changing the Context To make individuals’default decisions healthy
Socioeconomic Factors Largest Impact
Smallest Impact
Health Impact Pyramid Source: Dr. Tom Frieden, Director of the Centers for Disease Control and Prevention
2020 'Our vision is that by 2020 everyone is able to live
longer healthier lives at home, or in a homely setting. We will have a healthcare system where we have integrated health and social care, a focus on prevention, anticipation and supported self-management. When hospital treatment is required, and cannot be provided in a community setting, day
case treatment will be the norm. Whatever the setting, care will be provided to the highest
standards of quality and safety, with the person at the centre of all decisions. There will be a focus on ensuring that people get back into their home or
community environment as soon as appropriate, with minimal risk of re-admission.'
System designs that simultaneously improve: – the health of the populations; – the patient experience of care (including
quality and satisfaction); and – Per capita cost of health care
Outcomes (Clinical, PROMs, Experience) Cost to provide care Value =
Transitioning from Volume-based to Value-based Systems Requires New Mental Models
Swensen S, Pugh M, McMullan C, Kabcenell A. High-Impact Leadership: Improve Care, Improve the Health of Populations, and Reduce Costs. Cambridge, MA: Institute for Healthcare Improvement; 2013. Available on www.ihi.org.
Getting Started on the Triple Aim
§ Choose a relevant Population for TA
§ Articulate a Purpose to gel stakeholders
§ Choose Measures for the population
§ Develop a Portfolio (group) of projects
§ Develop Leadership and Governance
§ Develop a plan for Execution on projects and
accountabilities for results
| |
Diabetes – meaningful measurement
• Complications are costly… …in human terms …in disability terms …in dollar terms …and in terms of hospital utilization
• HealthPartners measurement: limbs saved, eyes saved, heart attacks prevented
0%
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50%
2Q04
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BeUer Health for PaGents with Diabetes
Measure: the % of pa8ents whose diabetes is well controlled:
Blood pressure under control (≤ 139/89) Healthy cholesterol (≤ 99)
Blood sugar under control (A1c ≤ 7.9) Non-‐smoker
Regular aspirin user
Be`er health, be`er experience, lower cost • 364 fewer heart aUacks • 68 avoided leg amputaGons • 625 prevented eye complicaGons • 1,200 fewer visits to the ER • $18,500 saved for paGents with
opGmally managed diabetes (numbers per year)
150,000 Stage 1 – Awareness
Stage 2 – Engagement Stage 3 – Accountability
Stage 4 – Culture of Health
Employee Triple Aim Metrics Actual
Metric 2012 2013 2014 2015Health: HRA 78.5 78.6 78.8 79 % Taking HRA Work Comp 0.78 0.8 0.79 0.78
Cost: PEPY (includes EE prem.) 9,517$ 9,707$ 9,998$ 10,298$ By Percent 2% 3% (ACA) 3% (ACA) Total Spend (Millions) 15.2 15.5 16 16.5 % Health Cost to Net Rev 3.7% 3.7% 3.5% 3.4%
Experience: % Wellness Cert. Completed 67% 71% 76% 80% % Lg. Claims (>$50K) 19% 20% 20% 20%
Notes:Mercer 2012 PEPY 10,558$ Mercer 2013 PEPY @ 5% 11,086$ ACA is 3% for 2014+
Goal
3 % Trend
79.3 2013
81% 2013
Improved Cost Bellin's Cost Difference Compared to Average
(In Millions)
-$2.1
-$1.3
-$1.2
-$0.6
-$1.1
-$2.0
-$1.7
-$2.6
-$2.5
-$2.2
$0.8
$0.5
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
$17+ Million Saved
OVER AVERAGE
UNDER AVERAGE
Improved Experience • Prevention: 71% compliance with age and gender
screenings – 4 years ago: only 20% of $50,000+ claims
• Large Cases ($50,000+): 24% reduction in cases, 34% reduction in spend – Percent Large Case Spend: 27% to 19% of total
spend
• Removing Barriers: Value-based primary care with 1,473 individuals in chronic care condition program generating 2,286 annual visits at an average visit cost of $147
Bellin Health: Employee Health Plan
High Risk Risk Range Score: > 6 (N=69) Goals: Control costs/coordinate care across conGnuum Example Programming: Targeted case management outreach
Moderate Risk Risk Range Score: 1.5 – 5.9 (N=616) Goals: Prevent further escalaGon of condiGons/risks/costs Example Programming: CondiGon specific programs, health coaching, disease, educaGon
Low Risk Risk Range Score: <1.5 (N= 4074) Goals: Keep healthy populaGons healthy and engaged Example Programming: Wellness programming, biometrics, HRA, prevenGon, screening
“The Rising Risk”
Segments Based on
Risk
www.integraGon.samhsa.gov
Summary 1. Context and paradigms
2. The Triple Aim
3. Opportunities: framing, segments
CREATING THE CONDITIONS, PART 1 (CONTINUED) Eibhlin McHugh Joint Director, Health and Social Care Partnership, Midlothian Council
Empowering Service Users with DemenGa and their
Families in Midlothian
Eibhlin McHugh Joint Director Health and Social Care
Partnership, Midlothian
Understanding the Experience of Service Users and their Families • Analysis exisGng services, data and pathways
• The views & experience of people who use services – narraGve research
• User/carer reference group/voluntary sector
• Outcomes based approach to performance
Redesigning Services • Post DiagnosGc support
• Local Area Co-‐ordinaGon and social isolaGon
• Carers support
Redesigning Services
• Family group conferencing
• Single demenGa service
• PiloGng care co-‐ordinator role
Extra Care Housing DemenGa Design
Our Ambi8on
Services underpinned by a culture of innovaGon that supports people with
demenGa to have the best possible quality of within their families and communiGes
Discussion ques8on
The Triple Aim is integral to the 2020 vision. What, if
anything, does your board need to do differently to
meet the Triple Aim?
Lunch break 12:35 – 13:20
Image source: http://lifegirl1130.files.wordpress.com/2010/06/teabreak.png
OPENING TO THE AFTERNOON SESSION Paul Gray Director General and CEO, NHSScotland
CREATING THE CONDITIONS, PART 2: BUILDING A QI INFRASTRUCTURE Pedro Delgado ExecuGve Director, InsGtute for Healthcare Improvement
Creating the conditions to
accelerate improvement – Part II
The Infrastructure Pedro Delgado Executive Director
Scotland Building a QI Infrastructure May 2014
To provide regional quality improvement exper8se and leadership in
order to enhance effec8veness and
impact of improvement
ini8a8ves (be`er health, be`er
care, lower cost)
Aim Primary Drivers Secondary Drivers
Genera8ng will for improvement in a region
Innova8ng in quality improvement
Execu8ng quality improvement ideas
Fostering a robust organiza8onal infrastructure
• Ability to idenGfy and measure gaps • Editorial and publishing skills and/or resources • Ability to convene a wide array of stakeholders
• Methods for harvesGng innovaGons • Methods for developing innovaGons
• Methods to build improvement capacity / capability
• Process to test new ideas • CapabiliGes in spread and scale-‐up • CapabiliGes in data management and measurement
• Process for evaluaGng improvement ideas
• Staffing and operaGons plans to facilitate QI work
• IT to support QI work • Structures and strategies for internal and external communicaGons
• The mission, vision, values and strategic plan all guide the work of the organizaGon
Quality and Innova8on Center Driver Diagram
Role of a QIC 1. Leadership and resources in a system or region for
focused and sustained attention to improving quality • Discover, test, and spread innovations and best practices • Build QI capacity and scientific thinking
2. Spark & support (system/regional/national) initiatives & demonstrate impact
• Build relationships, establish links, and connect people (physically and virtually) to learn, improve and innovate
• Offer technical and content expertise • Identify and coordinate disparate improvement activities • Influence policy and practice in their context
James M. Anderson Center for Health Systems Excellence
0
1
2
3
4
5 leadership
Publishing Improvement work
Convening
Harvesting Ideas
Developing innovative improvement ideas
Teaching Skills related to SOI
Improving capability in the SOI
Testing new ideas
Spread and Scale -Up
Evaluation and Data management
Internal Satffing and Operations Planning
Developing Support areas
Where are we ?
Infrastructure
Execu8on
Will
Ideas
10 Lessons
1. Constancy of purpose
2. Ambitious aims and pace of change
3. Transparency and pursuit of reliability
4. Measurement for improvement
5. Skills, time and space for improving
Purpose
Autonomy Mastery
Adapted from: Pink, D. H. (2009) Drive: The Surprising Truth about What Mo:vates Us. New York, NY: Penguin.
Intrinsic Mo8va8on 1. Constancy of purpose
2. AmbiGous aims and pace of change
3. Transparency and pursuit of reliability
4. Measurement for improvement
5. Skills, Gme and space for improving
1. Constancy of purpose
2. Ambitious aims and pace of change
3. Transparency and pursuit of
reliability
4. Measurement for improvement
5. Skills, time and space for improving
1. Constancy of purpose
2. Ambitious aims and pace of change
3. Transparency and pursuit of
reliability
4. Measurement for improvement
5. Skills, time and space for improving
Process Measures Quick Feedback Learning and Improvement Intermediate metrics
Outcome Measures Motivating Metrics More Complex Longer timeline
Build a Path:
Examples: Hand washing rates Lactate Levels Adherence to Bundles
Examples: Lives Saved Patients Delighted Affordability
1. Define, Test, Assess and Refine a Bundle of Key Elements • For broad use, focus on the Why, What and When • For Local adoption, customize the Who and How
2. Measure What Matters
81
Confidential & Proprietary
4. Measurement for improvement
5. Skills, time and space for improving
Deve
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Building PI Capability and Skills
Expa
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artm
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Deep
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Learning and sharing systems regionally and program-wide Improvement Institute
2009-2011 2012 and beyond
Portfolio Whole system
Continuous Improvement Project
Level of Project Difficulty
• Service line IA’s • All leaders know role
and skills • Prioritization and
oversight in operations • Alignment of portfolios • Standard work • Teams know goals and
test change
• Several Improvement Advisors
• Prioritization and portfolios
• Oversight groups • Sponsor and champion
accountability by service • Team development and
alignment of goals
• Improvement Advisor • Leadership • First project • Oversight responsibility • Several teams • 90 days
Mentors © Kaiser Permanente 2011 reproduce by permission only
7%
35%
Progress on Key Indicators: 2008 - 2012
52%
Hospital Standardized Mortality Ratio
BSI Rolling 12 Mo. Rate HAPUS Readmissions RFO
20%
Worker Injury Rates
Inpatient Utilization
83 | © Kaiser Permanente 2010-2011. All Rights Reserved. August 8, 2014
21%
54%
Cdiff
82%
30%
SRAES
19%
James M. Anderson Center for Health Systems Excellence
OperaGng AssumpGons • Building improvement capability at CCHMC goes beyond acquisiGon of
knowledge and skills to acGon-‐oriented improvement that achieves criGcal results and accelerates transformaGon.
• As an Academic Medical Center, CCHMC’s strategy for building improvement capability focuses on engaging and developing faculty as improvement leaders, educaGng trainees and advancing the scholarship of health care improvement through rigorous methods and quality improvement research.
• Different groups of people will have different levels of need for improvement knowledge and skill to achieve results, and each group should receive the training they need when they need it and in the appropriate amount.
• All members of the organizaGon should incorporate improvement into their daily work and have the ability to advance their improvement knowledge and skills to achieve criGcal results, and funcGon at any level of the CCHMC improvement ladder.
10 Lessons
6. Co-design and co-production
7. Exploration beyond healthcare for ideas
8. Behave their way to a culture change
9. Measure financial impact of initiatives
10. Celebrate success—and reward it
6. Co-‐design and co-‐producGon
7. ExploraGon beyos
8. Behave their way to a culture change
87
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% de Ninos q Trajeron Jugo -- Centro Parvularia Percent
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N Vasos de Agua Tomados por Ninos Presentes Rate
PDSA Health – Obesity prevenGon Classroom Centro Parvulario
Plan & Do Goal: To eliminate sugar-‐sweetened beverages and increase water consumpGon in preschool classrooms
Sugar sweetened beverages
Water consumpGon
** experience can actually change both the brain's physical structure (anatomy) and func:onal organiza:on (physiology)
NEUROPLASTICITY changes in neural pathways and
synapses which are due to changes in behavior, environment and neural
processes, as well as changes resulGng from bodily injury
“Based on our performance, we can confidently and conserva:vely expect to harvest at least a 5:1 return on
investment for value crea:on work”
10 Lessons – local, national, global
6. Co-design and co-production
7. Exploration beyond healthcare
for ideas
8. Behave their way to a culture
change
9. Measure financial impact of
initiatives
10. Celebrate success—and reward
it
1. Constancy of purpose
2. Ambitious aims and pace
of change
3. Transparency and pursuit
of reliability
4. Measurement for
improvement
5. Skills, time and space for
improving
Key Elements of An Assets/Strengths-Based Approach
1. Focus on the capacities or gifts that are present in the community, not
what is absent
2. Stress local leadership, investment, and control in both the planning
process and the outcome
3. Surface both formal, institutional resources (such as programs, facilities,
and financial capital) as well as individual, associational, and informal
strengths and resources
4. Seek to link the strengths and priorities of all partners, including the
people
Achieve Brown County Vision Brown County is a collabora8ve, thriving, inclusive community.
Mission Create a coordinated, accountable and connected community that prepares all children and youth to become engaged, successful adults which will result in a vibrant and sustainable Brown County.
Goals
Every child is prepared for
school.
Every child succeeds in school.
Every youth is connected to and engaged in educa8on/ training/ employment pathways.
Every youth a`ains post-‐secondary, con8nuous educa8on or career
training.
Every youth is equipped to become an effec8ve and engaged ci8zen.
Age Range 0-‐4 5-‐18 10-‐18 18-‐24 18-‐26 5-‐26
Outcomes
Children are developmentally ready to enter kindergarten.
Children meet grade-‐level expecta8ons.
Children are supported outside of school.
Youth create and regularly assess
their post-‐secondary and career plans.
Youth a`ain a college degree within 6 years.
Youth a`ain industry-‐,
government-‐ or military-‐recognized
license/ cer8fica8on.
Young adults are gainfully employed.
Children, youth and young adults contribute to community in a posi8ve way.
Contrib
u8ng In
dicators
• 3rd grade reading scores • 8th grade math scores • Dropout rate • A`endance rate • 9th and 10th graders college-‐ready • Deten8ons, suspensions and expulsions
• Alcohol and drug use • Children/youth avoiding risky behaviors • Children/youth who can iden8fy at least one consistent, posi8ve adult role model • Low socioeconomic children/youth with access to out-‐of-‐school 8me programs
• Parent and their child develop a career/college pathway • Student par8cipa8on in a work-‐based learning program • FAFSA submission by high school seniors
• Adults comple8ng one or more years of post-‐secondary educa8on or voca8onal training • Adults earning a post-‐secondary degree/ cer8ficate/ license by age 24
• Adults comple8ng one or more years of industry, government, or military training • Adults earning an industry, government, or military cer8ficate/ license by age 24
• Young adults self-‐sufficient by age 26 • Youth engaged in the labor force by age 24 • Adults holding stable employment for at least one year • Adults engaging in household forma8on, including homeownership
• High school students avoiding risky behavior • Secondary students engaging in volunteer service • Children and young adults age 5-‐26 involved in community organiza8ons
• Children entering 5K with age-‐appropriate: • language, literacy and thinking skills • social and emo8onal behavior • gross motor skills
Create a coordinated, accountable and connected community that prepares all children and youth to
become engaged, successful adults which will result in a vibrant and sustainable Brown County.
o
Birth – 4 years old 5-‐18 years old 10-‐18
years old 18-‐24 years old 18-‐26 years old
5-‐26 years old
Children develop-‐mentally ready to enter
kindergarten
Outcome Team #2
Outcome Team #3
Outcome Team #4
Outcome Team #5
Outcome Team #6
Outcome Team #7
Outcome Team #8
Backbone TeamExec. Director, Data Manager,
Facilitator, Support Staff
Outcomes Collaborative Steering Team
Community Leadership Council:Chairperson-‐Tim Weyenberg, Vice chair-‐ Mark Ka iser, Nancy Armbrust, John Benberg, Chuck Cloninger, Steve Harty, Tom Hedge, Denis Hogan, George Kerwin, Tony Klaubauf, Tom Kunkel, Damian LaCroix, Michelle Langenfeld, Greg Maass, David Pamperin, Ed
Pol icy, Fr. Dane Radecki, Laurie Radke, Jeff Rafn, Ashok Rai, Jen Van Den Elzen, Sue Vincent, Don White, Tod Zacharias
Achieve BrownCountyCommunity Accountability
Outcome Team #1
Children meet grade
level expectations
Children are
supported outside of school
Youth create and regularly assess their
post-‐secondary and career
plans
Youth attain a college degree within 6 years
Youth attain industry,
government or military recognized license/
certification
Young adults are gainfully employed
Children, youth and young adults contribute to community in a positive
way
Community Engagement Partners
Brown County United Way GGB Chamber of Commerce GGB Community FoundaGon
Summary 1. QIC
2. 10 Lessons
3. Assets
CREATING THE CONDITIONS, PART 2 (CONTINUED) Elaine Mead Chief ExecuGve, NHS Highland
NHS Highland Our Quality Journey
Elaine Mead Chief ExecuGve
May 2014
PuPng quality first to deliver BeRer health, BeRer care and BeRer value
50 days to fit (!)
Captures the spirit of how NHS Highland is working to improve care and outcomes for
people…
and describes the way we want to….
“do things here in Highland”
Our Quality Journey
Looking back ...2005
Looking forward
Remote and Rural
Resource Constraints
IntegraGon
PopulaGon Changes
Target Delivery
Person Centred Care
Values
Priori8es
Methods
Sustainability
PuPng quality first to deliver Be=er health, Be=er care and Be=er value
Board ambiGon & statement
IntegraGon, IntegraGon, IntegraGon
2005 2011-‐13 2035
IntegraG
ng Health
S
tructural Change
Re
-‐design Work
Re-‐de
sign Work
Re-‐de
sign Work
Re-‐de
sign Work
CollaboraGon
• Unscheduled care • Managed Clinical Networks • DiagnosGcs • Planned Care • Primary Care • 18 RTT
• Elizabeth Bradbury • Kurtosis • Manchester • Carlisle • Clayhanger
Trend in bed days by type of admission, Highland residents 2001 -‐2012
Percentage Compliance with the Four Hour Target: July 2007 to March 2013NHS Highland and NHS Scotland
NHS Scotland
NHS Highland
88%
90%
92%
94%
96%
98%
100%
Jul-07 Jan-08 Jul-08 Jan-09 Jul-09 Jan-10 Jul-10 Jan-11 Jul-11 Jan-12 Jul-12 Jan-13
Month
Per
cent
age
of p
atie
nts
spe
ndin
g le
ss th
an fo
ur
hour
s in
A&
E
Step Action New Behaviour
1 Increase Urgency People start telling each other, “Lets go, we need to change things”
2 Build the guiding team
A group powerful enough to guide a big change is formed and they start to work together.
3 Get the vision right The guiding team develops the right vision and strategy for the change effort.
4 Communicate for buy-in
People begin to buy into the change, and this shows in their behaviour.
5 Empower action More people feel able to act, and do act, on the vision.
6 Create short-term wins
Momentum builds as people try to fulfil the vision, while fewer and fewer resist change.
7 Don’t let up People make wave after wave of changes until the vision is fulfilled.
8 Make change stick New and winning behaviour continues despite the pull of tradition, turnover of change leader,
Framework for Change From the “Heart of Change”, Ko`er & Cohen, 2002)
2008
‘efficiency without quality is unthinkable; quality without efficiency is unsustainable’
Real opportunity for radical change
CATALYSTS FOR
CHANGE
18 weeks Referral to Treatment
Financial pressures
November 2009
What do we need to do….? • Maximise the use of our assets • Maximise the use of our talents • Maximise the use of our contracts • Understand and reduce variaGon
November 2009
Doing things that are of no clinical benefit to the pa8ent
Lean strategic partner
imaginaGon at work
Clinical engagement
Standardising approaches Measurement
Leadership • Board support • Engagement
Clarity and consistency • Clear vision • Highland context
Measurement • QI Tools and techniques • Investment in training
What makes improvement work?
No needless deaths No needless pain No helplessness
No unwanted waiGng No waste
…for anyone
IHI
7 characteris8cs of service delivery
Board Annual event November 2011
Promo8ng good health, self care and independence
High quality, integrated, equitable, needs & evidence-‐based, and cost effec8ve
Increasingly community-‐based, hospital beds for most acutely ill or those needing specialist care
Integrated and complimentary with the local authority, voluntary and independent sector care
Run by healthy, mo8vated and well-‐trained staff, working to their maximum poten8al and capability
Using modern, flexible, efficient, green assets to maximum effect
Using modern, flexible, efficient, green assets to maximum effect
Zero wastage inefficiency across all services, no unnecessary overheads
Boston MA
IHI Fellowship
Lesley-‐Anne Smith
IHI Boston
Stanley Cup
Paris 2012
Don Berwick Paris 2012
• How will this affect quality? • How will this affect the poor? • How will this affect costs?
Virginia Mason Medical Centre
IniGal Learning
• NHS Highland IHI Fellow had visited US sites, so pre-‐exisGng contacts
• Senior clinical staff visit to Virginia Mason – Saw system in acGon – Spoke to staff – Took part in Improvement work
• Back in UK, applied learning by developing overall approach
Strategic Framework 2012
• promoGng good health, self care and independence • high quality, integrated, equitable, needs and evidence-‐based, and cost-‐effecGve • increasingly community-‐based with hospital beds preserved for the most acutely ill and those with specialist needs • integrated with, and complementary to, local authority, voluntary and independent sector care • run by healthy, flexible, well-‐moGvated and well-‐trained staff working to their maximum potenGal and capability • using modern, flexible, efficient, green assets to maximum effect with zero wastage and inefficiency across all services and no unnecessary overheads
Strategic Framework
Service CharacterisGcs
Corporate ObjecGves
The Q&E Plan 2012/14(aka The Big Plan)
Harm Variation Waste……………….. Person-centered ………………..
SPSP(Acute and Mental Health
Falls
Pressure Ulcers
Sepsis
VTE
Medication errors
Care Pathways
COPD
Stroke
Dementia
Falls
Endoscopy
Admin & Clerical
Corporate Services
Care CapacityBeds
BodiesBuildings
âLOS
âAdmissions
âReadmissions
Medicines
Qua
lity
Cos
ts
Space Utilisation
The Big Plan
Long Term Vision
5 Year Goals
Annual ObjecGves
Annual Plan
2012 Values
• Do we recognise our behaviours? • Do our behaviours reflect our stated values? • Why do we jusGfy our behaviours with a ‘but’? • Do we know how we make people feel?
September 2012 Customer Care
“Is my BUT more important than your BUTT”
Being open and connecGng
Fi~ng HQA together
• Brings together the strands of governance, improvement and culture to deliver beUer care and experience to individuals
• IdenGfies prioriGes for work, based on organisaGonal objecGves and available evidence
• Uses Quality Improvement approaches and methods
North East England
Tees Esk &Wear Valley
Developing Infrastructure
• Appointed Director of Quality • Set up Quality Hub • SPSP and ProducGve Series already in place • Staff and paGent experience – new work stream
• Quality objecGves -‐ GEMBA • Lean
Lean Leader Training
• Trained or in training: – 5 of 9 Directors – 5 senior clinicians – 19 senior managers
• 16 Rapid Process Improvement Workshops undertaken since April 2013, up to 25 more this financial year
Lean
• Established a Kaizen PromoGon Office • Awareness training for staff – 2,000 people • Lean Leader training – contracted with Tees, Esk and Wear Valleys to deliver training in Highland.
• Now jointly delivered and training six NHS Highland coaches.
Overproduction
Processing
Inventory Transportation
Defects
Time
Motion WASTE
Waiting for people or services to be provided Time when processes, people or equipment are idle
Waste related to costs for inspection of defects in materials and processes, customer complaints and repairs
Unnecessary movement or movement that does not add value Movement that is done too quickly or slowly
Conveying, transferring, picking up, setting down, piling up and otherwise moving unnecessary items
Unnecessary processes and operations traditionally accepted as necessary
Producing what is unnecessary, when it is unnecessary, and unnecessary amounts
Maintaining excessive amounts of supplies, materials, or information Having more on hand than what is needed and used
Breast RT RPIW
RPIW focus
Building aeroplanes
PaGent engagement
Coaching
Share & Spread
• RPIWs spread to Care-‐at-‐Home service • Improvement work in Mental Health • GP appointment system reorganised with a
local RPIW
Focus Methodology Culture
Some developments
• Database of all improvement acGvity, accessible on intranet
• Aligning training with University of SGrling undergraduate and postgraduate nurse training, Aberdeen undergraduate medical training, and post-‐graduate training
• Quality Award scheme developed
GoalsMay 2013• NHS Highland Quality Hub to be
establishedSeptember 2013• Endoscopy exemplar project
completeDecember 2013• 30 staff trained as Senior
Quality Improvement Practitioners. Clinical Fellows programme established
• 20 Rapid Improvement Workshops completed including cancer, PMS and discharge planning
July 2014• all NHS Highland staff to have
received quality improvement awareness training (waste, 5S and standard work)
• everyone able to be the Beauly porterDecember 2014• 100 staff will be trained as Quality
Improvement Practitioners• 40 RPIWs, 200 Kaizen events
undertakenMarch 2016• NHS Highland will be accredited to
provide LEAN training• one post minimum funded by income
Annual Review, July 13
Key Messages
• Have a clear sense of purpose and vision • Live by your values • Seek out, and send influencers to learn from
best in class • Build QI capability and capacity • Capture and communicate your stories • Celebrate and reward success
Its not easy!
Paris 2014
“I had a bit of an epiphany when I was in Paris. It was a tremendous opportunity for networking, even within my own NHS Highland colleagues” “I found it fascinaGng to have access to decision makers and hear about their backgrounds and moGvaGon.”
Step Action New Behaviour
1 Increase Urgency People start telling each other, “Lets go, we need to change things”
2 Build the guiding team
A group powerful enough to guide a big change is formed and they start to work together.
3 Get the vision right The guiding team develops the right vision and strategy for the change effort.
4 Communicate for buy-in
People begin to buy into the change, and this shows in their behaviour.
5 Empower action More people feel able to act, and do act, on the vision.
6 Create short-term wins
Momentum builds as people try to fulfil the vision, while fewer and fewer resist change.
7 Don’t let up People make wave after wave of changes until the vision is fulfilled. 8 Make change stick New and winning behaviour continues despite the pull of tradition, turnover of change
leader,
Framework for Change From the “Heart of Change”, Ko`er & Cohen, 2002)
Hold your nerve!
Discussion ques8ons
1. What challenges does your board face in successfully creaGng the condiGons for improvement?
2. What would help naGonally to create the condiGons for improvement?
Awernoon break 14:45 – 15:00
Image source: http://lifegirl1130.files.wordpress.com/2010/06/teabreak.png
CREATING THE CONDITIONS, PART 3: WHAT DOES GOOD LOOK LIKE? Panel discussion
LAST REMARKS & CLOSING Angiolina Foster CEO, Healthcare Improvement Scotland